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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 06/11/2026
Date Signed: 06/11/2026 12:02:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2025 and conducted by Evaluator Nadia Shahbazian
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250422083808
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:TANYA QUEZADAFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 74DATE:
06/11/2026
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Tanya Quezada- Executive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
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9
Staff does not ensure resident’s room is clean.
INVESTIGATION FINDINGS:
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5
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9
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13
**This report supersedes the report dated 08/27/25 to change the finding of allegation “Staff does not ensure resident’s room is clean” from Substantiated to Unsubstantiated and add additional information.**

On 06/11/26 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit and met with Tanya Quezada- Executive Director and explained the reason for the visit.

On 10/16/25 LPA Mariana Agban met Tannya Quezada, Executive Director, and delivered findings for the above allegation. On 6/19/25 LPA Agban conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations. On 4/23/25 LPA Agban conducted an initial complaint investigation visit.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20250422083808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 06/11/2026
NARRATIVE
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Regarding the Allegation: Staff does not ensure resident’s room is clean: It is alleged that facility staff do not clean R1’s room. Interview with R1 revealed that staff come to R1’s room to provide housekeeping services, however, R1 refuses staff to clean the room and provide laundry services. Interview with ten (10) residents revealed their rooms are clean and had no concerns regarding housekeeping services. Interview with the Executive Director revealed that R1 does not allow housekeeping staff in their room. The Executive Director mentioned that they have worked with R1 to declutter R1’s room, however, R1 would bring additional boxes into the room. LPA Agban observed R1’s room filled with storage boxes, recycling bottles, and stacks of paper. LPA also noted that R1’s bed sheets are not clean and have urine stains. LPA visited five (5) random resident rooms and observed the rooms to be clean.

Based on information obtained, the allegation is deemed Unsubstantiated as facility staff had provided housekeeping services; however, R1 refused to utilize it.

Other allegations remain the same.

Exit interview conducted, copy of this report signed and delivered.
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC9099 (FAS) - (06/04)
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